265. Endocrine emergencies

Question 1

What are the signs of DKA?

Answer 1

Gradual drowsiness, vomiting and dehydration

Ketotic breath, abdo pain, kussmaul breathing

Question 2

What is meant by kussmaul breathing

Answer 2

deep laboured gasping breathing seen in DKA

Question 3

What triggers a DKA?

Answer 3

Infection
MI
Pancreatitis (however serum amylase may be coincidentally raised)
Chemo
Antipsychotics
Insulin non compliance

Question 4

What three criteria are required to diagnose DKA?

Answer 4

Acidaemia (venous blood pH<7.3 or HCO3 <15mmol/L)

Hyperglycaemia (glucose>11 or known DM)

Ketonaemia (>3.ommol/L) or significant ketonuria (>2+)

Question 5

When should you consider transfer of the patient to HDU/ITU?

Answer 5

Blood ketones>6
Bicarb<5
pH<7
K<3.5
GCS<12
sats<92
BP<90 systolic
Pulse outwith normal parameters (60-100)

Question 6

Discuss the fluid requirements in an individual with DKA?

Answer 6

Typical fluid deficit is around 1L/10kg
0.9 % saline is the fluid of choice
So for 70Kg male:

1L in 1 hour (unless BP<90 systolic)
1L in 2 hours (x2)
1L in 4 hours (x2)
1L in 8 hours

bicarbonate may increase risk of cerebral oedema and is not used

Question 7

Discuss the need for potassium replacement in those with a DKA?

Answer 7

Depending on U&E’s add potassium to every bag after 1st bag:

K >5.5- Nil
K-3.5-5.5- 40mmol
K <3.5- get HDU involvement

Question 8

What is the treatment plan for DKA?

Answer 8

ABC and 2 large bore cannula

Fluid resus if required, if not start first bag over 1h

VBG,pH, bicarb, bedside lab glucose and ketones, bloods, check every 2 hours at least

Insulin- add 50 units per bag, continues patients normal insulin regime,

Check cap blood glucose and ketones hourly

Monitor urine output

When glucose <14mmol start 10% with insulin to avoid hypo

Question 9

What can be said when looking for infection in DKA?

Answer 9

High WCC may be seen without infection

Have low suspicion, do MSSU, blood cultures and CXR

Question 10

How may a DKA reoccur quickly after treatment?

Answer 10

Blood glucose may resolve before ketones do
Premature insulin discontinuation may lead to DKA

Avoid by keeping glucose and insulin infusion until ketones <0.5

Question 11

What are the signs of a hypo?

Answer 11

Rapid onset, odd behaviour

Sweating, pulse, seizures

Question 12

Once a hypo has been confirmed how is it managed?

Answer 12

Give 15-20g of a quick acting carbohydrate snack (e.g O.J.) (repeat up to 3 times every 15 mins)

If unconscious start glucose infusion or give glucagon

Once blood glucose above 4 give toast

Question 13

What is hyperglycaemic hypersosmlar state, how is it treated?

Answer 13

Type 2 DM, dehydration and glucose >30

Give LMWH to all that can take it

Rehydrate slowly with 0.9% saline. Replace potassium when urine comes

Question 14

What drug should be stopped in diabetics with a lactic acidosis

Answer 14

Metformin

Question 15

What is myxoedema coma?

Answer 15

The ultimate hypothyroid state before death

Question 16

What are the signs and symptoms of myxoedema coma?

Answer 16

Looks hypothyroid, often >65
hypothermia, low glucose, bradycardia
coma, seizures

goitre, cyanosis, low BP, HF

Question 17

What is the treatment of myxoedema coma?

Answer 17

ICU

Bloods for T3, T4, TSH, FBC, U&E’s, ABG

Give T3 slowly

Give hydrocortisone if pituitary hypothyroidism is suspected

Question 18

What are the complications seen in myxoedema coma?

Answer 18

Hypoglyceamia, pancreatitis, arrythmias

Question 19

What is a hyperthryoid storm?

Answer 19

Severe hyperthyroidsim increased temp, agitatioon, confusion,coma

Question 20

Who tends to get a hyperthyroid storm?

Answer 20

Recent thyroid surgery or radioiodine

Infection, MI, trauma

Question 21

What are the goals of treatment in a hyperthyroid crisis?

Answer 21

Counteract peripheral affects of thyroid hormones

Inhibit thyroid hormone synthesis

Treat systemic complications

Question 22

What is the management plan for a thyrotoxic storm?

Answer 22

IV access, fluids if dehydrated, NG if Vom

Take bloods for T3, T4, TSH, cultures

sedate if necessary, give propanalol to reduce heart rate/digoxin

Antithyroid drugs (carbimazole)

Hydrocortisone to prevent peripheral conversion

Question 23

What are the causes of an Addisonian crisis?

Answer 23

Infection, trauma, surgery, missed medication

Question 24

How does an Addisonian crisis present?

Answer 24

Shock (increased HR, vasconstriction, postural hypotension)

hypoglycaemia

Question 25

How do you manage an addisonian crisis?

Answer 25

Bloods for cortisol AND Acth
Hydrocortisone
IV fluid bolus
Change to oral steroids after 72 hours

Question 26

Hypopituitary coma should be suspected when a patient presents with hypothermia, refratory hypotension and septic signs

How is it treated?

Answer 26

Dont wait for lab results

Hydrocortisone

Liothyroxine (T3)

Question 27

Patients with phaeochromocytma may present with hypertensive crisis. How is this treated?

Answer 27

Short acting alpha blocker

Long acting alpha blocker, when BP stable

B blocker to control any tachycardia/arrythmias